Current through Register Vol. 48, No. 38, September 20, 2024
a) Definitions
As used in this Section, unless the context requires
otherwise:
1) "Batch Mode" is any
request other than a "real time mode" request. The Department will respond to a
"batch mode" request within 24 hours.
2) "Medical Provider" is a provider of
medical services who is enrolled with the Department to render services under
any healthcare program administered by the Department.
3) "Real Time Mode" is a request for
eligibility verification for a single individual, or a request for claims
status for a specific claim from a trading partner, to which the Department
will respond as immediately as possible.
4) "Recipient" is an individual eligible to
receive services through any healthcare program administered by the
Department.
5) "Subscriber" is a
medical provider or the agent of a medical provider who executes a contract
with a trading partner to participate in the EDI service.
6) "Trading Partner" is an entity that has
successfully completed the EDI trading partner application process and executed
an agreement with the Department to utilize the Department's EDI
service.
b) Electronic
Data Interchange (EDI) Service
A new Electronic Data Interchange process will offer a HIPAA
compliant means for trading partners to verify recipient eligibility (real time
and batch mode), submit medical claims (batch mode only) and check medical
claim status (real time and batch mode). This information will be made
available to medical providers through Department approved trading partners.
Trading partners are responsible for marketing the EDI service to medical
providers. Direct access to the EDI service will be made available through
Department prescribed methods. Only Department approved trading partners and
their subscribing medical providers are authorized to access information
provided through the EDI service, except as may be approved through subsection
(e)(4).
c) Recipient
Eligibility Verification (REV) System Contract Termination
The REV system (see Section 5-1.2 of the Public Aid Code)
offered on-line Medicaid eligibility information and claims history information
to subscribers through REV contractors. All REV vendor contracts that have not
been terminated are terminated effective June 30, 2013. Any REV vendor who had
a contract with the Department that has terminated must apply to become a
trading partner under subsection (d).
d) Eligibility Requirements for Trading
Partners
In order to be qualified to participate in the service, a
trading partner must:
1) Submit a
Department prescribed application to the Department and execute an agreement
with the Department. The agreement will establish the amount of reimbursement
the trading partner will pay to the Department for real time mode and batch
mode requests. The agreement will also provide that the provider or trading
partner will execute a written contract with each subscriber prior to any
exchange of data with that subscriber;
2) Agree to access data through one or more
high speed data transmission circuits determined by the Department to be
compatible with current technology and operating needs. Current compatible high
speed data transmission circuits shall be identified as part of the information
provided to applicants who request the application from the Department. Updates
to technology, operating needs or transmission circuits will be provided to
existing trading partners via electronic communication at least 30 days before
usage is required;
3) Treat all
information, including information relating to recipients and medical providers
obtained under the agreement with the Department as confidential information
pursuant to the Public Aid Code [305 ILCS 5 ] and federal regulations under the
Health Insurance Portability and Accountability Act of 1996 (HIPPA) ( 42 CFR
160, 162 and 164);
4) Provide data
to subscribers through a system designed to be flexible to meet each
subscriber's needs as well as meeting the following specific requirements:
A) Support various means of telecommunication
that are commonly available for use by the subscriber; and
B) Be compatible with the State of Illinois
Department of Central Management Services' current electronic communication
protocols;
5) Certify
that it is neither an individual nor an organization that:
A) Furnishes statements or bills and receives
payment in the name of medical providers; or
B) Advances money to a medical provider for
accounts receivable that the medical provider has assigned, sold or transferred
to the individual or organization for an added fee or a deduction of the
portion of the accounts receivable.
e) Subscriber Contracts
The trading partner must agree that all contracts with
subscribers provide that:
1) Access to
the system shall be restricted to the sole purpose of verification of medical
assistance eligibility, submission of medical claims, and providing claims
history information when a subscriber is requesting payment information for
medical services rendered to a recipient;
2) The subscriber indemnifies and holds
harmless the State, its agents and employees from any and all claims by the
subscriber or any recipient who is aggrieved by the actions of any party under
the contract;
3) The subscriber is
an enrolled medical provider or the medical provider's agent;
4) A third party who is not qualified as a
subscriber may be granted access to the EDI service through a trading partner
only with prior approval of the Department;
5) All information, including information
relating to recipients and providers obtained by the subscriber, through
performance under contract with the contractor, is treated as confidential
information pursuant to the Public Aid Code [305 ILCS 5 ] and federal
regulations under the Health Insurance Portability and Accountability Act of
1996 (HIPPA) ( 42 CFR 160, 162 and 164); and
6) The subscriber will certify that neither
it, nor any employees, partners, officers or shareholders of the subscriber,
are currently barred, suspended or terminated from participation in the
Medicaid or Medicare program, nor are any of the above currently under sanction
for, or serving a sentence for, conviction of any Medicaid or Medicare program
offenses.
f) Charges for
EDI Services
1) Reimbursement rates for real
time mode and batch mode requests from a trading partner will be established in
the agreement between the trading partner and the Department.
2) Charges to the subscribers are made in
accordance with the fee schedule and provisions specified in the contract
between the trading partner and subscriber.
